Current through September 21, 2024
(a) Assessment of
the Heart Attack Patient.
(i) EMS providers
shall maintain a high index of suspicion that a patient may be suffering a
myocardial infarction or acute coronary syndrome when the patient presents with
signs or symptoms that include, but are not limited to:
(A) A prior history of myocardial infarction,
acute coronary syndrome, or other cardiac related health problems;
(B) Chest pain;
(C) Pain or discomfort in other areas of the
body (e.g. arm, jaw or epigastrium) of suspected cardiac origin;
(D) Shortness of breath;
(E) Sweating;
(F) Nausea or vomiting;
(G) Dizziness;
(H) Atypical or unusual symptoms,
particularly in women, the elderly, and diabetic patients;
(I) Congestive heart failure (CHF);
(J) Syncope or shock.
(ii) The 12-lead ECG is the primary
diagnostic tool that identifies an ST segment elevation myocardial infarction
(STEMI). EMS providers shall acquire a 12-lead ECG, and transmit the recording
as soon as possible for all patients.
(b) Triage of the Heart Attack Patient. Heart
attack patients shall be triaged to the most appropriate facility based on the
index of suspicion formed by the cumulative assessed findings.
(c) Treatment of the Heart Attack Patient.
The care provided by EMS providers shall be directed toward reducing the
following time factors:
(i) The time between
the first indication of a myocardial infarction or acute coronary syndrome and
the administration of aspirin;
(ii)
The time between the arrival on scene to the time of 12-lead ECG
acquisition;
(iii) The time between
12-lead ECG acquisition and transmission of the recording;
(iv) The time between 12-lead ECG acquisition
and the identification of a STEMI;
(v) The time between the identification of a
STEMI and notification of the findings to the receiving facility;
(vi) The time between the onset of a STEMI
patient's symptoms and their ultimate arrival at a PCI center;
(vii) The time between EMS agency
notification and the time of activation of a cardiac catheterization
laboratory;
(viii) The time between
arrival at the PCI center and the time of cardiac catheterization
(door-to-balloon time);
(ix) The
time between prehospital 12-lead ECG acquisition and the time of cardiac
catheterization (ECG-to-balloon time).
(d) ALS personnel shall assess the patient's
cardiac rhythm utilizing a cardiac monitor and 12-lead ECG and treat in
accordance with the appropriate local protocols and standing orders.
(e) If the patient is dyspneic, hypoxemic, or
has obvious signs of heart failure and there are no other contraindications,
EMS providers shall perform the following to the extent allowed by the
individual's scope of practice:
(i) Titrate
oxygen therapy to achieve an oxygen saturation of greater than or equal to
94%;
(ii) Administer aspirin -
chewable, non-enteric-coated, 160 to 325 mg is preferred;
(iii) Establish intravenous access;
(iv) Transmit a 12-lead ECG at the earliest
opportunity for remote interpretation or confirmation by a physician;
(v) Provide advance notification as soon as
possible to the receiving hospital for patients identified as having
STEMI;
(vi) Perform serial ECGs and
make copies of all ECGs available to treating personnel at the receiving
hospital, whether they are presented in hard copy or transmitted from the
field;
(vii) Administer
nitroglycerin (tablets or spray) every three to five minutes as long as the
patient's systolic blood pressure remains greater than 100mmHg.
(A) Nitrates in all forms are contraindicated
in patients with a systolic blood pressure less than 90 mmHg, in patients with
suspected right ventricular infarction, or when patients have taken an erectile
dysfunction medication within 24 hours, or within 48 hours of the use of
tadalafil (Adcirca, Cialis);
(viii) Analgesia is indicated in STEMI when
chest discomfort is unresponsive to nitrates. Morphine should be used with
caution in unstable angina due to an association with increased
mortality.
(f) Transport
of the Heart Attack Patient. Ambulance destination decisions shall be
preferential based on the following descending order of preference and
capability:
(i) Heart Attack Receiving Center
or a hospital with a PCI facility;
(ii) Heart Attack Referring Center;
(iii) A hospital with an emergency
department.
